What is the indication for catheter-guided thrombolysis in pulmonary embolism (PE)?

From the Guidelines

Catheter-guided thrombolysis for pulmonary embolism is indicated for patients with acute, massive pulmonary embolism who have hemodynamic instability, or for selected patients with submassive PE who have evidence of right ventricular dysfunction and elevated cardiac biomarkers. The procedure involves direct delivery of thrombolytic agents such as tissue plasminogen activator (tPA) through a catheter positioned within the pulmonary artery thrombus, aiming to dissolve the clot while minimizing bleeding risks compared to systemic thrombolysis 1.

Key Considerations

• Patients should be evaluated for contraindications to thrombolysis, including recent surgery, active bleeding, history of hemorrhagic stroke, or other high bleeding risk conditions.
• The procedure should be performed by experienced interventional specialists in centers with appropriate expertise and capabilities for managing potential complications.
• The rationale for this approach is that direct delivery of thrombolytics to the clot allows for more rapid restoration of pulmonary blood flow, reduction in pulmonary artery pressure, and improvement in right ventricular function while potentially reducing systemic bleeding complications.

Clinical Evidence

• A meta-analysis of noncontrolled trials favors catheter-directed thrombolysis over systemic thrombolysis, with an NNT of 13 for preventing death and 5 for preventing major complications 1.
• Current practice guidelines recommend systemic thrombolysis for massive PE, but recognize the potential safety advantage of using a catheter-directed approach 1.

Patient Selection

• Patients with massive PE who have contraindications to fibrinolysis, or who remain unstable after receiving fibrinolysis, may benefit from catheter embolectomy and fragmentation or surgical embolectomy 1.
• Patients with submassive PE who have clinical evidence of adverse prognosis, such as new hemodynamic instability, worsening respiratory failure, severe RV dysfunction, or major myocardial necrosis, may be considered for catheter embolectomy or surgical embolectomy 1.

From the Research

Indications for Catheter-Guided Thrombolysis in Pulmonary Embolism (PE)

The indications for catheter-guided thrombolysis in pulmonary embolism (PE) include:

• Submassive or intermediate-risk PE with right ventricular strain 2, 3, 4, 5, 6
• Massive PE with hemodynamic instability 2, 5
• Patients who have contraindications to systemic thrombolysis 2, 3
• Patients who fail systemic thrombolysis 3

Patient Selection

Patient selection for catheter-guided thrombolysis in PE is based on:

• Presence of right ventricular dysfunction or strain 2, 4, 5
• Severity of symptoms, such as dyspnea 4
• Extent of thrombus burden and lung obstruction 5
• Presence of contraindications to systemic thrombolysis 2, 3

Clinical Outcomes

Clinical outcomes of catheter-guided thrombolysis in PE include:

• Improvement in hemodynamic parameters, such as pulmonary artery pressure 2, 4, 5
• Reduction in thrombus burden and lung obstruction 4, 5
• Improvement in right ventricular function 5
• Low rates of major hemorrhage and other complications 2, 3, 4, 5, 6